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The Problem with Quality
Author: Brett Patterson, NAED
Copyright: Copyright 9-1-1 Magazine, Feature Content
By Brett Patterson, NAED
Originally published in our April, 2008 issue.
Quality Improvement (QI) is a relatively new concept in emergency communications. Called by many names, including Total Quality Management or Control, Quality Assurance, and Statistical Quality Control, among others, QI has existed in the modern era since post WWII Japan when quality experts like Dr. W. Edwards Deming and Joseph M. Juran helped to re-industrialize the war-torn country. It wasn’t until decades later, much to the chagrin of Dr. Deming and others who witnessed, firsthand, the transformation in Japan, that the United States began to take serious notice of QI principles, particularly in the manufacturing sector. By the 1980s, however, QI programs had become more popular in the hospitality service industry, eventually spreading to general healthcare and, currently, into EMS and emergency communications. Today, one is more likely to hear conversations about what type of QI program is best, rather than whether or not the implementation of a QI program is truly necessary.
In reality, there are only minor process differences among QI experts that primarily involve methods. The philosophy remains much the same: utilize empowered and educated employees to dissect and measure processes, understand and analyze variation, provide applicable training to workers, and institute change that reduces variance and improves the process.
With regard to emergency communications, QI programs evolved from the calltaking process, probably because of the popularity of dispatch protocols that enabled measurement of the process. Before the advent of such protocols, the calltaking process was basically freelanced and highly variant, making performance measurement all but impossible. However, as protocols have become recognized as essential in the non-visual realm of medical dispatch in particular, QI programs have emerged as a way to maintain compliance to protocol and provide managers with a way to track performance.
At this early stage of development, QI programs in emergency communications have not been universally successful. Most commonly, dispatchers complain about the measurement process as being destructive and disciplinary in nature, benefiting only supervisors and managers by providing job security for those in charge of checking for errors and punishing the wrongdoers. This common flaw is likely linked to poor implementation processes that institute measurement and feedback prior to the critical components of commitment, from the top down, and basic QI education for all involved.
A QI process that involves only measurement to a standard and feedback of poor results is doomed to failure because it is incomplete. It can be compared with an attempt to fly using only power and an aircraft, without the knowledge necessary to interpret the flight data and adjust the complex controls accordingly. While measurement to a standard is critical to the QI process because it establishes a baseline from which to measure improvement, without a complete understanding of other vital factors, the measurement process can be as destructive as it is potentially productive.
First and foremost, QI begins with philosophy. There must be a commitment, from the top management, to the basic principles of QI and to the significant effort it will take to educate all involved and implement a complete process. Everyone must understand that the ultimate goal of QI is to make life better for everyone, from the shareholder to the worker to the customer, and that all must be involved in the process. Involvement and empowerment are critical as QI philosophy teaches us that changing processes without employee involvement only creates resentment; involvement equals ownership and, ultimately, by-in.
Although a complete teaching of the philosophy and tools of a sound QI process is too detailed to describe here, the basic components are simple, and education regarding those components are within easy reach of committed managers. Once employees, supervisors, and managers understand basic QI philosophy (what is about to happen, and why, and how it will make life better for everyone), implementation can begin.
Using the scripted, calltaking process as an example, the first step is baseline measurement. Assuming that calltakers now understand why they are being “graded” (this poor choice of words is only being used to make a point about poor feedback practices), the well-trained auditor (someone with both dispatch and field experience, protocol expertise, and QI training specific to the protocol being used as well as the basic tools and understanding of QI measurement, analysis, and feedback), audits a random selection of calls and establishes some baseline measurements and interprets the results.
The seemingly simple process of baseline measurement requires an understanding of randomization and variation. Unless the calls being audited are randomized properly for each calltaker, the data collected cannot be considered accurate. For example, if a month’s worth of calls are randomized, but only two calls for a particular calltaker are captured, and one of those calls is non-compliance, a score of 50 percent is obtained, which is not likely to be reflective of the calltaker’s actual performance. For this reason, a statistically significant sample must be randomized for each calltaker to ensure the validity of the data and prevent the unintentional but nevertheless destructive practice of feeding back inaccurate data.
Once a process has been measured, the data must be correctly analyzed for variation. Although performance improvement is the ultimate goal, reducing variation is what makes that process possible as it enables efficient and effective feedback and education. A statistical control chart, easily constructed mathematically in modern computer software, helps the auditor and/or trainer to distinguish random from special-cause variation.
Random variation is normal within any process and can be reduced when education is geared towards everyone involved. Once the process is under control (random variation is within control limits), education can be more specific to primary causes of non-compliance, which are easily discovered using other QI measurement tools such as the Pareto chart. On the other hand, special-cause variation, identified as variation outside of designated control limits, allows the trainer to focus limited resources on those who are clearly outside the limits of random variation, thereby gaining control of the process before attempting to raise the bar with more universal efforts.
Appropriate measurement and analysis enables accurate feedback and efficient and effective education that is very specific to the deficiencies discovered during the process. Just as importantly, it enables the positive feedback that employees need to remain excited about their work.
Another benefit of the QI process is that when properly implemented, QI can distinguish between the poor application of a process versus a poor performing process. This differentiation is essential because it prevents the ineffective application of resources towards employees when, in actuality, the process is deficient, or vice versa. This is why compliance to protocol is so essential to protocol evolution; without strict compliance, one cannot judge whether the outcome of the process is related to the protocol or to the more random decision-making process of individual calltakers.
QI systems have proven essential to industries where quality really matters. NASA requires quality to ensure pinpoint accuracy. The service industry relies on quality to bring back customers. Healthcare, and now the entire spectrum of public safety, is increasingly relying on QI principles, tools, and techniques to take care of and protect the public. Currently, our biggest challenge is not embracing QI, but rather implementing it correctly. This requires a commitment from management, a thorough QI education for those responsible for the measurement, feedback, and training involved, and the empowerment of employees to make change when change is justified. This can be accomplished with a little research. Read about quality, talk with and visit those with successful programs, and join a local or internet-based QI forum. Above all, know what you are doing, before you do it, and you will be more likely to do it right.
Brett Patterson is an Academics and Standards Associate for the National Academies of Emergency Dispatch (NAED). He is a senior EMD instructor, a member of the NAED College of Fellows, Standards Council, and Rules Committee. He also serves as the Academy’s content editor and Research Council Chairman. Brett became a paramedic in 1981 and began a career in EMS communications in 1987. Prior to accepting a position with NAED he spent ten years working in a public utility model EMS system in Pinellas County, Florida.